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Title: Feasibilty of extended treatment time on haemodialysis and effects on patient outcomes
Author: Singh, Seemapreet Kaur
ISNI:       0000 0004 6061 4987
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2015
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The majority of patients requiring renal replacement therapy are dependent upon haemodialysis (HD). Although outcomes have improved significantly, the prognosis for patients reliant on HD remains sub-optimal. To improve outcomes the focus has been on intensive dialysis regimens, primarily facilitated by more frequent or intermittent nocturnal HD but with limited results. Centres advocating extended treatment time (TT), along with international registries, have demonstrated an association between extended TT and improved patient outcomes. But, the feasibility and efficacy of providing extended TT within in-centre thrice weekly shift-based day-time dialysis has not been formally examined. This thesis examines the effect of extended TT of 6 hours on thrice weekly HD versus standard TT of 4 hours in a prospective randomised cross-over study and demonstrates improved blood pressure control, nutritional status, patient experience and quality of life. This is despite both the 6-hour and 4-hour arms exceeding the minimum national dialysis dose target, as measured by a quotient of small molecule clearance, spKt/V. This finding challenges the accepted use of spKt/V as a single marker of adequate dialysis and promotes the use of a composite of meaningful patient-centred outcome measures alongside hard clinical endpoints. To assess the feasibility of extended TT within shift based day-time HD provision the opinions of both local and national staff were surveyed. The survey results provided unique insights into the difficulties of limited slots contrasting with increasing patient numbers and the limited circumstances under which extended TT is prescribed. This is primarily in patients who would otherwise be under-dialysed, indicated by a below target spKt/V. This thesis advances knowledge of the impact of extending TT as a means of intensifying HD prescription on markers of nutritional status, cardiovascular disease and patient experience. These findings justify incorporation of TT in HD quality standards.
Supervisor: Brown, Edwina, ; Pusey, Charles ; Duncan, Neill Sponsor: National Institute of Health Research
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral